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Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist ("skilled care") are necessary for the performance of a safe and effective maintenance program. Medical necessity is required for all services covered under Medicare, as is the requirement that the services be skilled. 2. Was skilled therapy needed? Here are some additional guidelines for defensible documentation: In Touch EMR is a fully integrated scheduling, documentation and billing software for physical therapy practices. Cold pack x 10 minutes in supine following ther ex. With most healthcare practices, there are forms that need to be completed by the patient prior to the initial examination by the therapist. When treating patients, use shorthand to take quick personal notes about your interactions and observations. Thanks Patient instructed in UE bike to maximize UE ROM and strength for improved overall function in tasks. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Physical therapy documentation should explain what the patient is doing, and what it is that the provider is doing / the manner in which the provider is contributing to make the treatment process billable as skilled care that is medically necessary. Physical therapy documentation can be time-consuming and confusing for a PT team. No assistive device used. PT ceased task to reduce and direct program toward pain management. The patient reports having knee pain for years before he consulted with an ortho surgeon in August of 2015. OT modified tasks as needed to allow therapeutic rest needed to maximize strength and functional tolerance. Provide some details about the onset of injury. Because SOAP notes are in-depth summaries of a physical therapy appointment, they require focus and dedication. endobj The handbook provides information about Texas Medicaid's benefits, policies, and procedures applicable to these therapies. Hint 1: It is a good idea to include direct quotes from the patient in this section. This creates a vicious cycle where wedocument too much. hb``` ,|qcb N%DX44KK W?58[zD=h0h`@F@ 4e'i^ [`B+3]1`|Gy 'C*H3* -H30.{HQYJ :9Y An X-ray revealed severe arthritis and the patient elected to undergo total knee replacement in December of 2015. In supine, patient positioned properly to train in posterior pelvic tilts, abdominal crunches 2x 15. The patient will tolerate feeding self with minimal assist, occasional verbal cues and hand under hand technique 100% of meals with occupational therapy to maintain current weight at ______ lbs.